In this and the previous issue of The Health Psychologist three articles (and a section of my column) have discussed a new concept in the delivery of psychological services called integrated primary care (IPC). The specifics of this new practice are articulated in the current issue in articles by Tulkin & Guzman and Bruns & Johnson and were discussed in the previous issue in an article by Daniel Bruns. All of these articles focus on the experience of Kaiser Permanente of Northern California. Please review these writings for specifics regarding the conceptual basis for integrated primary care and its implementation at Kaiser. Many thanks are due to these contributors for enlightening all of us regarding this potentially exciting development in health psychology/behavioral medicine practice.

While reading these manuscripts I have had many thoughts and questions. In this column I will share some of my concerns and I invite readers to send in their comments for presentation in the spring issue. The conception and implementation of integrated primary care is certainly innovative and revolutionary but, like all novel treatment paradigms, its ultimate impact on patient care, outcomes, and satisfaction - as well as health care costs - is still unknown. Apparently, the idea was born out of the realization that primary care physicians were spending an inordinate amount of time practicing in areas where they lack expertise - namely, managing problems that were largely, perhaps in some cases totally, psychological in nature. This approach to treatment was deemed ineffective in terms of both patient outcomes and health care costs. Bruns and Johnson also note that integrated primary care developed from a population management perspective for planning and intervention as opposed to working from an individual patient perspective.

As I mentioned in the last edition of the newsletter, my experience in behavioral medicine is that many (not all) physicians refer to the psychologist when other treatments have failed or when the doctor has become exasperated with the patient. Thus, the psychologist is often the "treatment of last resort." Clearly, this type of practice is less than optimal for all concerned parties and is likely to, in the end, result in higher costs with less successful outcomes. To the extent that integrated primary care eliminates this reluctance to refer for psychological services it appears to be a promising step in the direction of better outcomes and, perhaps, lower costs. Yet, the 15-30 minute triage practice also raises several questions, namely, are psychologists really able to adequately and effectively treat or refer on the basis of such time limited interventions. Tulkin and Guzman acknowledge that they have encountered resistance to integrated primary care from psychologists who believe that integrated primary care will further erode the practice of psychotherapy. In response they note that patients needing intervention at the secondary or tertiary levels are referred appropriately and only those who can benefit from the brief primary interventions remain in that treatment format. But is our profession in a position to, with accuracy, know quickly which patients will benefit most in which treatment program? I am continually impressed with how often the identified presenting problem ends up being only the ticket into the office and, in actuality, has very little to do with what is really troubling the patient. I typically do not, however, understand this in any particular case until some time into the therapy process, often after a couple of hour long sessions. Once this determination is made treatment can often progress rather quickly, but what will happen to these patients in the integrated primary care format?

Further, although Tulkin and Guzman clearly discuss the necessity of referral to the proper treatment modality for all patients, Bruns and Johnson offer an interesting example of utilizing resources based on population perspectives. They suggest that resources should be expended in ways that impact the greatest number of people. Their example of the 100 hours with 100 panic patients in the emergency room versus 100 hours with one borderline patient is worrisome and raises questions about resource allocation and by whom and how those decisions should be made.

The parallels with medical treatment are obvious. A major concern that many people have with health maintenance organizations is the HMO's willingness to treat the inexpensive yet common problems to the exclusion of the more expensive and idiosyncratic disorders. This issue was recently highlighted at my university when a patient's physicians strongly recommended bone marrow transplantation. The procedure was denied insurance reimbursement even though it is generally covered by the contract, because in her particular case it was considered by the insurers to be "experimental." Newspaper accounts of the incident noted that many in the university community argued that they could pay out-of-pocket for inexpensive procedures (e.g., routine physician visits) but desired insurance precisely for these catastrophic life or death incidents. Similarly, regarding psychological services, one wonders if the population based philosophy will generate wonderful brief treatments for mild conditions while leaving those suffering from disorders requiring more intensive and longer term treatment uncovered and untreated.

Several other issues caught my attention in these two pieces and I will briefly mention them. First, is it completely positive to have financial incentives coordinated under one organization? This type of control can certainly create efficiency but the potential for abuse also seems notable. Again the model of HMO service in medical practice is relevant. Second, how solid will the outcome data be and what aspects of those data will be determinative in terms of policy and treatment decisions? Measuring outcomes is a complicated and multidimensional process that is inherently influenced by the values of the research team. Even more value laden, however, are the decisions based on the outcome data. For example, what happens if integrated primary care psychologists refer so many patients for additional psychological services that costs, at least initially, go up? Would successful long-term patient outcomes be enough to outweigh these costs? Further, would rates increase or would psychologists be pressured to refer less often and treat more in the primary setting? Finally, how will the integrated primary care paradigm affect relationships between psychologists and physicians, most notably psychiatrists, in the long-run? Will insurers eventually decide to employ other, often less expensive non-psychologist mental health professionals in these integrated primary care positions? After all, don't social workers routinely staff crisis hotlines and provide other very brief triage activities and interventions?

Obviously many questions remain for discussion concerning the practice of psychologists in primary care settings. The experiment described in the preceding articles is a novel and exciting one that is certainly worth our careful attention. It has the potential to reduce health care costs while at the same time increasing successful patient outcomes and opening new doors for professional psychological practice. Let's keep our fingers crossed and wish the best to those involved.

By way of recommendation, for those of you interested in reading about patient-doctor issues from a physician's perspective I recommend The Lost Art of Healing by Bernard Lown, M.D. He is a Nobel Prize winning cardiologist from Boston who has a great deal to say about the doctor-patient relationship and what he believes to be curative in medicine.

Any readers interested in entering into the discussion of integrated primary care please direct your comments to me at <kevinm@fs1.ed.usus.edu> .

Read response: Medical Treatment, Moral Dilemmas, and Integrated Primary Care

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